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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208925
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:47:52 AM

Document Has Been Signed on 03/29/2022 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:NOBLE SERVANT HOMESFACILITY NUMBER:
107208925
ADMINISTRATOR:SOCIAS, KRISTINA FAITHFACILITY TYPE:
740
ADDRESS:4140 W. CAPITOLA AVETELEPHONE:
(559) 492-7005
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 3DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kristina SociasTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Infection Control Inspection. LPA met with Administrator Kristina Socias. LPA entered through the central entry point where Health Screening and temperature was taken. Hand sanitizer was observed at entry.

Infection control procedures which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation requirements, quarantine/isolation procedures, staffing, PPE and daily infection control procedures. All 3 residents are fully vaccinated.

LPA toured the facility inside and out. Required postings as well as Covid-19 and hand washing signs were observed. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed 30-day resident medication, adequate food storage and PPE. Bathroom sinks are stocked with liquid soap and paper towels.


No deficiencies cited during today’s visit.


A copy of this report will be provided via email to noble.servant.homes@gmail.com. An exit interview was conducted with the Administrator.

LPA requested the following updated forms by 4/5/22: LIC 308, LIC 500, LIC 610E, LIC 9020 and a copy of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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